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Payment Policies Update - November 2021

Date: 09/23/21

Thank you for your continued partnership with Sunflower Health Plan. As you know, we continually review and update our payment and utilization policies to ensure that they comply with industry standards while delivering the best patient experience to our members.

Sunflower Health Plan will be implementing the following policies and prepay edit updates effective November 1, 2021.

Policies

  • CC.PP.070 - 340B Drug Payment Reduction (Medicare) - Ensures that providers participating in the 340B Drug Pricing Program are correctly reporting 340B acquired drugs according to guidelines established by the Centers for Medicare and Medicaid Services (CMS).
  • CP.MP.208 - Outpatient Testing for Drugs of Abuse: Presumptive Frequency Edits (Medicare, Marketplace) - Medical necessity criteria for presumptive (preliminary) testing for a specific drug and frequency limits for 80305, 80306, and 80307 for chronic opioid therapy.

Prepay Edits

  • WCG Integration Value Capture – Correct Coding Batch 2 (Cotiviti 8, WCIVC B2) (Medicare, Marketplace) - The purpose of this policy is to serve as a reference guide for general coding and claims editing information. Cotiviti 8 is a correct coding edit of ICD-10 diagnosis codes. Source: ICD-10 CM Diagnosis Code Manual. EX Code: wd Diagnosis Code Incorrectly Coded Per ICD-10 Manual
  • Procedure Modifier Revenue Necessary (PMRN) - Correct Coding Batch #3 (Medicare) - The PMRN edit will deny procedures that require an associated modifier and also identify situations where a correct modifier and revenue code are required. The edit applies to both professional (HCFA) and outpatient facility (UB-04) claims.
    • Per CMS and AMA, procedures that can be performed on different sides of the body, separate anatomical areas, or separate patient encounters, require the use of modifiers whenever appropriate.
      Additionally, on professional claims, each code designated as “always therapy” must always be furnished under an SLP, OT, or PT plan of care and as such must always be accompanied by one of the therapy modifiers.
    • Medicare recognizes the services furnished under the OPT service benefit as either “always” or “sometimes” therapy. “Always therapy” codes require modifier GN, GO, or GP appended to the therapy CPT code.
    • CMS approved “sometimes therapy” codes require the appropriate modifier and revenue code combination when furnished by a therapist.
  • Flexible Provider Matching (Medicare, Marketplace) - Expanding the reviewed claim areas to determine if the providers are part of the same group and specialty as outlined in CMS guidelines.
  • ClaimXten Optimization Study Phase I (Medicare, Marketplace) - The addition of prepayment edits to comply with CMS NCDs.

For detailed information about these policies, please refer to our Clinical and Payment Policies page.

If you have questions about this bulletin or other provider resources, please contact your Provider Relations Representative or call Customer Service at:

  • Ambetter from Sunflower Health Plan (Marketplace): 1-844-518-9505 (TTY 1-844-546-9713)
  • Allwell from Sunflower Health Plan (Medicare Advantage):
    • HMO 1-855-565-9519
    • HMO D-SNP 1-833-402-6707
    • PPO 1-833-696-0634
    • TTY 711